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Medical Myths

Are there really five stages of grief?

About the author

Claudia is a writer, broadcaster and lecturer in psychology. She presents Health Check on BBC World Service every Wednesday and her new book is titled Time Warped: Unlocking the Mysteries of Time Perception.

If there are myths you’d like Claudia to bust in future columns, she’s on Twitter @claudiahammond.

Are there really five stages of grief?

(Copyright: Thinkstock)

People often talk about a set pattern to bereavement, but Claudia Hammond examines whether the evidence shows that everybody shares the same experience.

“Grief turns out to be a place none of us know until we reach it. We anticipate (we know) that someone close to us could die, but we do not look beyond the few days or weeks that immediately follow such an imagined death.” Joan Didion’s candid account of bereavement in The Year of Magical Thinking provides a powerful experience of what it is like to lose a loved one.

People often talk about the five stages of grief – denial, anger, bargaining, depression and acceptance. The five stages are taught across the world, have made appearances in TV’s The Simpsons and The Office, and the artist Damien Hirst created a series called DABDA, named after the acronym for the five stages. There is no set timeframe for passing through these stages, but they have become accepted as part of the normal pattern of grief.

The concept originates from work done in the 1960s by John Bowlby, the psychologist who became known for his work on attachment between babies and their parents, and Colin Murray-Parkes, who has written a huge amount on bereavement. Together, they identified four stages of grief from interviews with 22 widows: numbness, searching and yearning, depression and reorganisation. Then Elisabeth Kubler-Ross, famous for changing attitudes towards the treatment of the dying, carried out a series of interviews with terminally ill people, and devised the five stages we know of today to describe the experience of facing impending death – though didn’t test them in any systematic way. Their appeal was such that soon the same five stages were being used to describe other sets of emotional reactions, such as grief.

Noting its widespread use without any systematic evidence for such a set pattern, researchers from Yale University tested the five stages in the early 2000s. As lists of the five stages vary slightly from source to source they settled on examining disbelief, yearning, anger, depression and acceptance. For three years they collected data as part of the Yale Bereavement Study – in total 233 people were interviewed approximately six, eleven and nineteen months after a loved one (usually a spouse) had died. Those whose relatives had a violent death or who were suffering from what is known as a complicated grief reaction were excluded.

The resulting picture was more complex than the five stages would suggest. The researchers found that acceptance was the strongest emotion throughout, while disbelief was very low. The second strongest emotion throughout was yearning, and depression was more evident than anger at every stage. Also, emotions did not replace each other in some form of orderly sequence; the highest point of any of those emotions did follow the correct sequence, but a person in the third stage, for example, would still experience acceptance most strongly, not anger.

After six months the researchers found that all negative emotions were beginning to decline, but bear in mind that this doesn’t mean that people were somehow “over it”. It’s common to miss the deceased profoundly for years to come, but most people do cope. Also bear in mind that for ethical reasons the researchers could only begin the interviews a month after bereavement, so they had no picture of an initial month that could include conflicting emotions.

Time heals

A study published a few years later included the response to violent deaths too, but this time the bereaved were college students, and so the majority had lost more distant relatives than spouses. Again, the stages were not closely followed, although the researchers found that distress was higher earlier on and acceptance was higher later. But unlike the other study they didn’t follow people over time. The researchers had taken a snapshot in time, so they couldn’t tell whether any one individual was passing through the stages, just that those who were bereaved six months ago tended to differ from those bereaved a year ago.

Another study confirmed that older people do not respond in a set way. George Bonanno from Columbia University followed people before their bereavement, enrolling older couples in the study and then checking the local newspaper obituaries every day for any deaths. He found that 45% genuinely did not experience severe distress after the death of their spouse, nor did they are as time went on – 10% of the widows even showed improved mental health. People were resilient and were able to cope with the death of their spouse. Bonanno’s most recent research, published last year, confirms a lack of set pattern.

Whatever the evidence suggests, the five-stages-of-grief idea is certainly an appealing one, in the sense that it could give people hope that however bad they are feeling now, at least they will eventually move through the stages and feel better. But when I interviewed Ruth David Konigsberg, the author of The Truth About Grief, who has investigated the five stages, she told me it could also set up expectations amongst the grief-stricken that they should be feeling a particular way. “It’s reassuring for people who experience some of the emotions, but it’s stigmatising for those who don’t,” said Konigsberg. “You may feel you’re grieving incorrectly or there’s something wrong with you.”

But, as studies show, there is no “correct” or “incorrect” way to grieve: the same experience isn’t shared by everybody, nor should it be expected to. The loss is always there, but for most the grief changes over time. That doesn’t mean that everyone has to experience every stage or even that feelings will appear in that order. It might be reassuring to have a script, which shows you where you are heading next, but sadly real life experiences aren’t always as neat at the theories describing them. Life is messier than that.

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